Documentation of Capacity and Capability of the Northern California Thalassemia Center (NCTC) Prior work experience in conducting and addressing the research and programmatic objectives of the Research Initiative for the Prevention of Complications of Thalassemia Since its establishment 17 years ago, the NCTC has developed a growing statewide program dedicated to delivering comprehensive multidisciplinary care, subspecialty services, community outreach, and opportunities to participate in research trials. The primary site of the NCTC is Children's Hospital and Research Center Oakland (CHRCO) and a network of seven satellite medical centers throughout the state of California. As one of only a handful of comprehensive thalassemia centers in the nation, the NCTC is a rare resource and authority on many issues related to thalassemia. It is home to some of the most experienced thalassemia researchers and healthcare providers in the world, has an active and wide-reaching outreach program, and boasts an excellent infrastructure and an exemplary record of research and dissemination. Since 2002, the NCTC has participated in CDC grant U27/CCU92210, offering comprehensive multi-disciplinary care to patients throughout California, providing outreach and education to patients and communities, playing a lead role in national research trials in thalassemia, and enrolling patients from CHRCO in the CDC Thalassemia Universal Data Collection Program and investigations of sero-conversions and suspected blood borne pathogens. In addition to its ongoing participation in the CDC trial [unreadable]Prevention of the Complications of Thalassemia,[unreadable] we have coordinated multi-center research trials, assumed a leading role in the Thalassemia Clinical Research Network, and undertaken numerous basic, clinical, and translational research studies. A clear description of the populations to be reached and how they will be identified, enrolled and made part of all research initiatives In 2006, the NCTC provided comprehensive care to 140 thalassemia patients at Children's Hospital and Research Center at Oakland (CHRCO), a 12% increase in the number of patients seen in the previous year. Of these 140, 42% have beta thalassemia and 43% are transfusion dependent. Approximately 51% are women and 75% are of Asian descent. Within the entire network of CHRCO and its satellites, nearly 400 patients across California receive care through the NCTC. In 2006, 91% of the patients in the NCTC received a comprehensive annual visit. During these comprehensive annual visits, and via widely disseminated research flyers and outreach efforts (including over 60 activities in 2006), patients are educated about ongoing research initiatives at the NCTC. More than 300 NCTC patients have consented to participate in research studies through the TCRN alone. Outreach to both the identified thalassemia community and the at-risk population has been a top priority and continues to be a mainstay of the NCTC's work. The tremendous influx in the Asian population and growing awareness of thalassemia and its complications have created an increased demand for patient services, education, and counseling statewide. Recently, the NCTC expanded efforts into new Asian communities within the Stockton, Fresno, and San Jose areas and to the Middle Eastern and Indian communities. The NCTC website continues to offer updated information about thalassemia, new research and clinical trial opportunities, and allows individuals to email questions to NCTC. An outline of the surveillance data collection systems in place and how they will be employed and expanded to support and underpin the programs to be implemented under this new project Infections are the second most common cause of death in thalassemia major. Pathogens are transmitted by blood transfusion, and altered host immunity from hypersplenism and iron overload contribute to the morbidity. Specific transfusion protocols are followed and all transfused patients are screened annually for hepatitis B surface antibody, surface antigen and core antibody and HIV. Transfused patients are also screened annually for hepatitis C surface antibody and if positive, PCR for hepatitis C is measured. Liver function tests are obtained every 3 months and if elevated, patients are again screened for hepatitis B, C, and A;CMV, EBV, Parvovirus, and HIV. These protocols and infrastructure have supported the enrollment of 55 patients from NCTC on CDC U27/CCU922110. Continued funding will allow us to follow these patients annually with ongoing specimen collection and shipping to the CDC and completion of annual data forms. We will also be able to enroll an additional 30 patients over the next funding cycle. A full range of services and screening for complications are available for thalassemia patients at the NCTC. The Hemoglobinopathy Reference Laboratory at NCTC is the reference laboratory for the State of California Newborn Screening Program. We are the only program in North America to universally screen all births for both beta-thalassemia and alpha-thalassemia. Patients are referred to the center through newborn screening and outreach activities. We have been successful in providing annual comprehensive exams to over 90% of patients with the goal of providing annual screening, surveillance and treatment for iron overload, heart disease, liver disease, endocrine dysfunction, nutritional deficiencies and disorders of bone metabolism. Our future goals include expanded screening for cardiac iron deposition using newly available MRI technology and pulmonary hypertension. Indications of research hypotheses and research questions to be addressed and answered throughout the life of this new award cycle The NCTC continues to take a leading role as PI or Co-Pi on almost all of the protocols for the TCRN. In addition, several investigators at the NCTC are recipients of K and other research awards and are coordinating independent studies in thalassemia. Examples of current research hypotheses under investigation include: 1) Deferoxamine (DFO) and deferiprone (L1) combination therapy improves left ventricular function more rapidly than DFO/placebo therapy among transfusion dependent beta-thalassemia patients with abnormal resting ejection fractions, 2) Arginine and sidenafil will both show clinical efficacy in the treatment of pulmonary hypertension, 3) Nine months of administration of low-dose subcutaneous decitabine can produce clinically significant (2-3g/dl) increases in total hemoglobin in patients with thalassemia intermedia, 4) Antioxidant therapy with a combination of RS-Alpha-Lipoic Acid (LA) and L-Carnitine (ALCAR) will produce a measurable decline in oxidative stress in patients with thalassemia, 5) Increased platelet activation and hypercoagulability is the primary cause of the development of pulmonary hypertension, and 6) Zinc supplementation can improve bone health as measured by bone mineral density, bone strength, and markers of bone formation and resorption in beta-thalassemia patients. Presentation of completed and in-process studies undertaken with an indication of how new data and research will contribute to enhanced outcome-based initiatives for patient identification, clinical care and follow-up, including family and caregiver dynamics. A major focus of the NCTC is to undertake outcome-based research that will result in improved diagnosis and treatment of patients with thalassemia and assistance for their families. Our multi-disciplinary approach to outcome-based research addresses the wide spectrum of problems facing this disease that range from cultural obstacles affecting immigrants to new iron chelators, nutrition1-6, management of medical complications, and experimental therapy7-11. These subjects are briefly summarized here and are referred to throughout the text. We are California's Reference Hemoglobinopathy Center for newborn screening and the NIH-sponsored central Hemoglobin Diagnosis Laboratory for North America12-16. This has given us the opportunity to prospectively monitor the epidemiology of thalassemia17-20. Long-term, prospective follow-up of newborns who have undergone DNA and genetic modifier diagnosis has enabled us to better understand the genotype/phenotype correlations20-23. Information from these studies has led to the establishment of North America's only universal alpha-thalassemia screening program, defined the clinical importance of Hb H Constant Spring, Hb E Thalassemia6, 24-29 and other new variants30-32. In addition, there is ongoing research to understand the cultural and social impact of thalassemia on the changing ethnic groups33, 34. Iron overload and its management The NCTC is the principal investigator on several approaches to improve iron chelation and monitor their toxicity. This includes the development of new chelators, including long-acting starch Desferal35, and combination therapy with deferasirox and Desferal36. In addition, we are the co-investigator on several prospective trials evaluating deferiprone37, deferasirox, continuous desferal for cardiac disease or cardiac hemosiderosis. Linked to the new chelators is a comprehensive program addressing non-invasive technology to diagnosis iron overload including new studies measuring pituitary, gonadal, and cardiac iron with SQUID and MRI38-43. Management of complications Treatment of thalassemia requires evidence-based information. Our program focuses on prospective studies to prevent and improve the diagnosis and treatment of complications5, 25, 44-53. Complications and therapy under study include aspirin, arginine, sildenafil for pulmonary hypertension, antioxidant supplementation, combination therapy for hepatitis54, 55, surveillance programs of blood safety13, new approaches to cardiac disease7, preimplantation therapy for pregnancy56, 57, and the problem of transitioning patients into adulthood58. New therapy Our approach to therapy has focused on fetal hemoglobin F modulator trials, including hydroxyurea, darbepoietin, and recently Decitabine25, 26, 59-63. In addition, we have been prospectively evaluating new approaches to stem cell transplantation in order to decrease morbidity and increase access for patients without allogeneic matches64-67. NorthernGaliforniaThalassemiaCenterNarrativePublic Information TheNorthernCaliforniTahalassemiCaenterseekstoexpanditsworkproviding comprehensivmeedicaclaretothalassemipaatientsandthoseatriskfor complicationfthisdisease.Ourmissionalsoincludesmonitorinbgloodsafety amongtransfusion-dependtehnatlassemipaatientsa,ndprovidingoutreachand educationservicestoallat-riskpopulationtshroughoutht estate.